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Article 67

Passport to Wholeness

The Effects of a Campus Mental Health Fair on Help-Seeking Attitudes

Lucinda C. West and Anita Knight

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A university campus-wide event titled Passport to Wholeness was designed to increase awareness of health and wellness issues and decrease stigmas toward mental illness. A follow-up study of 375 students compared the scores on Fischer and Farina’s (1995) Attitudes Toward Seeking Professional Psychological Help-Short Form (ATSPPH-SF) between attendees and non- attendees. Attendees of Passport to Wholeness scored higher on help-seeking than non-attendees at the 90% confidence level; the difference was not enough for statistical significance. Participants were asked if they were more likely to refer to a professional after attending the event, resulting in a statistically significant difference between the attendees and non-attendees (attendees were more likely to refer). Stigma toward mental health was noted in the sample. Males scored significantly higher than females on the ATSPPH-SF, which is contrary to other literature. Lessons learned and keys to producing a successful campus-wide event are discussed.

Introduction

College counselors provide services to treat a full range of personal concerns such as anxiety disorders, eating disorders, substance abuse, relationship issues, and violent behavior including suicide attempts (Spooner, 2000); however, stigma attached to mental health combined with lack of social support prevent students from seeking professional help (Heeney, & Watters, 2009; Wilcox, Arria, Caldeira, Vincent, Pinchevsky, & O'Grady, 2010). Suicide is the second leading cause of death in college students (Wilcox, Arria, Caldeira, Vincent, Pinchevsky, & O'Grady, 2010). Coping mechanisms include self-medication, alcohol abuse of stimulant medication (e.g. Ritalin), and escapism (Park & Levenson, 2002). College students struggle to find appropriate methods of coping with stress and increased work load.

Literature on college students’ mental health has indicated the trend or perception of more psychopathology than in the past (Dean, 2000; Humphrey, Kitchens, & Patrick, 2000; Meadows, 2000; and National Mental Health Association, 2002). Gallagher (2009) produced an annual report of information provided by college and university counseling center directors. He noted a trend toward increases in serious mental illnesses on campus. For example, 25% of clients were taking psychiatric medication. This number increased by 5% from the report in 2003, 8% since 2000, and 16% since 1994. Demands for individual services were escalating as more students were already on psychotropic medication; more than 7% of clients in Gallagher’s study were unable to remain in school without extensive psychological/psychiatric help. The directors reported 48% of their clients having severe psychological problems.

Wellness researchers (Myers, Sweeney, & Witmer, 2000; Smith, Myers, & Hensley, 2002) indicated a need for holistic methods of treatment and prevention designed to tap into mind, body, and spirit including areas of spirituality, self-care, nutrition, exercise, stress management, self-worth, education, career and employment, creative expression, culture, gender identity, and others. Further, college counselors (Bigard, 2009) have developed creative measures to promote wellness and counseling services on campuses. Mental health fairs are a relatively new concept. Myers et al. (2000) and Chandler, Holden, and Kolander (1992) identified spirituality as the hub of their wellness models. The six dimensions of Chandler et al.’s (1992) “holistic wellness model,” (i.e., spiritual, intellectual, emotional, social, occupational; p. 171) served as the foundation for the present mental health event. We adopted their model and added financial wellness as a seventh dimension.

A few organizations have produced mental health events hosted by their company on college campuses (e.g., Kristin Brooks Hope Center, 2011), aimed at suicide prevention. These can be costly. Further research needs to determine their effectiveness in increasing help-seeking attitudes and referrals.

The limitation of services and the growing psychopathology is creating a challenge for college and university counselors. Counselors need to clarify the limits of their services and maintain an adequate referral network (Dean, 2000; Humphrey et al., 2000; Meadows, 2000; National Mental Health Association, 2002). Budgets and resources are tightening. Additionally, students must be willing to seek help and follow through on referrals. In this regard, referrals require seeking help two or more times from multiple sources.

Purpose

The purpose of this study was to determine whether the campus-wide mental health and wellness fair influenced help-seeking attitudes of university students toward professional psychological help, and whether evidence of stigma toward mental health problems exists on the campus (e.g., bias, distrust, stereotyping, fear, embarrassment, anger, avoidance). Researchers have noted that stigma decreases sense of community due to social distance, especially true toward people with schizophrenia (Heeney & Watters, 2009; Norman, Sorrentino, Windell, & Manchanda, 2008). Stigma and lack of awareness of resources deterred those in need from seeking professional help (U.S. Department of Health and Human Services, 1999). The New York Times Health Guide has begun to encourage those with severe mental illness to share their stories in an effort to “change the stigma,” featuring several men and women diagnosed with schizophrenia or schizoaffective disorder including a CEO of a nonprofit organization (Barrow, 2010), but stigma is still evident on college campuses. Passport to Wholeness was designed to raise awareness of mental health and related wellness issues as well as increase visibility of resources found in a particular university campus and external community.

The literature supports a need for this type of campus-wide activity on university campuses. For example, the Surgeon General’s latest report indicated a need for decreasing stigma, increasing public knowledge of the connection between medical and mental health, and finding innovative ways to disseminate knowledge (U.S. Department of Health and Human Services, 1999). Programs have been developed in universities to emphasize the holistic wellness approach (Broughton, 2001; Smith et al., 2002). The mental health fair in this study combined issues of mental health with general health to provide a more holistic view focused on the mind- body connection and total well-being.

In addition there is a need on college campuses to strengthen the faculty-staff referral base (Nolan, Pace, Ianelli, Palma, & Pakalns, 2006) through strengthening faculty relations with the campus counselors and other counseling staff. Nolan and colleagues speak of the importance of obtaining referrals from faculty and staff. The referrals in Nolan and colleagues’ study indicated faculty and staff who were oriented to their counseling center early in the year were significantly higher on number of referrals than the control group (who did not refer even one student). Half of those faculty or staff who went through the orientation program referred at least one student.

Methods

The Event

The Passport to Wholeness event and causal comparative follow-up study were performed at a mid-size (approximately 3,000 students), private university in the southeastern United States. After obtaining approval from the university’s Institutional Review Board, the pre-event planning occurred during the summer months. Student Life staff provided information on campus policies and event planning, access to materials and personnel, and proffered a small grant ($400.00) from their budget. (There were no funds available in the counseling budget.) The campus nurse championed several booths, disseminating information on diabetes, women’s issues, healthy eating, and other health related topics. Staffers solicited support from churches, community agencies, drug and alcohol facilities, fitness centers, and sponsors. Psychology faculty incorporated presentations on various mental illnesses into their courses as a group project. Other faculty required students to attend the fair as a course requirement or offered extra credit for attending.

Forty booths of varying size and design lined the main plaza on campus representing the seven domains of wellness previously mentioned. Several tents were available for shade, with music to attract attention. The event was “kicked off” in a morning program where all students were encouraged to attend, and continued through the lunch hour, lasting a total of 4 hours. All departments on campus helped produce and support the event, with the campus counselors as the lead.

Along the Passport to Wholeness theme, students received a small pocket-sized Passport made of card stock to encourage participation in multiple booths along the plaza. The more signatures obtained, the more opportunities they had to win a prize. Booth sponsors contributed to giveaways. The event utilized limited resources.

Our Passport to Wholeness health and wellness fair targeted students as well as faculty and staff in an effort to increase awareness of resources, and to increase our referral base. Referral forms were available for faculty and staff. However, we observed the faculty and staff had a tendency to shy away from the booths and did not participate as readily as did the students. This phenomenon lends room for future studies and more effective means to market to faculty and staff. We only included students in our study due to the limited faculty and staff involvement. In addition, we considered a pre-post experimental study of help-seeking attitudes; however, the university’s Institutional Review Board denied this request due to the necessity of tracking students to match the pre-post test scores. Therefore, we conducted a post-test causal comparative design to test differences between the groups of attenders and non-attenders.

The Study

We asked the following research questions in developing our study.

Q1: Will university students who attended the Passport to Wholeness event score higher on the scale Attitudes Toward Seeking Professional Psychological Help-Short Form (ATSPPH- SF; Fischer & Farina, 1995) than those who did not attend the event?

Q2: Will university students who attended the Passport to Wholeness event score higher on the “Likely to Refer” question (#21) than those who did not attend? (Question 21 states, “I am more likely to refer a friend to a professional counselor now than I was prior to the Passport to Wholeness event.” Participants rated their level of agreement on a 4-point Likert scale 3) Agree, 2) Partly agree, 1) Partly disagree, 0) Disagree.)

Q3: Does stigma toward mental health exist on the present university campus?

Questionnaires with Informed Consent (SurveyMonkey®) were sent via email link to all students 1-, 2- and 3-weeks after the event until saturation occurred. The primary instrument used to measure the construct of help-seeking was the Attitudes Toward Seeking Professional Psychological Help-Short Form (ATSPPH-SF; Fischer & Farina, 1995). This is a shortened scale for measuring willingness to seek help from mental health professionals based on the original scale developed by Fischer and Turner (1970). It is free to use and requires no permissions to administer. According to Elhai, Schweinle, and Anderson (2008), the short version has demonstrated internal consistency ranging from 0.82 to 0.84, one month test–retest reliability of 0.80, and a correlation of 0.87 with the longer scale among prior samples of college students. Elhai et al. (2008) also tested the shortened scale for validity and reliability on college students (coefficient alpha of 0.77) and medical patients (coefficient alpha of 0.78). The ATSPPH-SF correlated − .41 with a Stigma Scale for Receiving Psychological Help (SSRPH, P < 0.001) for construct validity, indicating that higher ATSPPH-SF scores and more favorable treatment attitudes were associated with less stigma-related treatment concerns for the medical patient group. Participants who score higher on the ATSPPH-SF (Fischer & Farina, 1995) are more likely to seek professional help and have decreased stigma toward mental health.

The instrument has ten questions represented by a newly devised two-factor model; Openness to Seeking Treatment for Emotional Problems (OSTEP, items 1, 3, 5, 6 and 7) and Value and Need in Seeking Treatment (VNST, items 2, 4, 8, 9, and 10). Elhai et al. (2008) indicated a confirmatory factor analysis testing the new two-factor model found in the college student exploratory factor analysis yielded evidence for a moderately good fit, χ2(34,N=394)=84.57, P<0.001.

Participants respond to a 4-point Likert scale whether they agree or disagree with statements such as #1 “If I believed I was having a mental breakdown, my first inclination would be to get professional attention” (3=Agree, 2=Partly agree, 1=Partly disagree, 0=Disagree) and #9 “A person should work out his or her own problems; getting psychological counseling would be a last resort” (reverse scored 0=Agree, 1=Partly agree, 2=Partly disagree, 3=Disagree). Participants were also asked 15 questions including 3 demographic questions and 12 questions including referral attitudes, awareness of resources, personal experience with professional services, attendance, and reflections on the Passport to Wholeness event.

In addition to the drawing held at the event, participants who completed the post-event study had the opportunity to place their name in a drawing for a $25.00 gift card. Attendance at the event or completion of the Passport was not necessary for participation in the study. Identifying information was separated from survey data to maintain confidentiality of participants.

Participants

We used a convenience sample based on responses to a mass email survey sent to the student body. There were 375 respondents for a total of 350 completed surveys. Of the respondents, 133 participants indicated they had attended the event, and 32 of the participants indicated they also completed the Passport booklet; 205 participants indicated they had not attended the event, although a few indicated they had walked passed the booths on their way to class or did not respond to the question.

Among the participants, 28% were male and 72% were female (N=372); 65% lived on campus and 35% lived off-campus (N=375). The sample was tested for a normal distribution of the data using the Kolmogorov-Smirnov test and the data is found to be normally distributed.

Results

Q1: Will university students who attended the Passport to Wholeness event score higher on the Attitudes Toward Seeking Professional Psychological Help-Short Form (ATSPPH-SF; Fischer & Farina, 1995) than those who did not attend the event?

There was no significant difference on the ANOVA (p=0.068) on the scores of the ATSPPH-SF between attendees and non-attendees (we failed to reject the null). However, there was some provisional support for the first research question in that there was an actual difference at the 90% confidence level.

Q2: Will university students who attended the Passport to Wholeness event score higher on the “likely to refer” question (#21) than those who did not attend? Question #21 states, “I am more likely to refer a friend to a professional counselor now than I was prior to the Passport to Wholeness event.” A one-way analysis of variance was conducted using SAS Enterprise Minor in order to evaluate the relationship between attendance of a mental health fair and higher scores on the “likely to refer” question (#21), “I am more likely to refer a friend to a professional counselor now than I was prior to the Passport to Wholeness event.” The independent variable was attendance of the mental health fair, Passport to Wholeness. The dependent variables included the various help seeking behaviors measured by the ATSPPH-SF. The ANOVA was significant F(2) 3.057, p. 048. The strength of the relationship between attendance of the event and the (higher scores on #21) likelihood to refer, is strong (if they attended, they scored significantly higher on the "likely to refer" question).

We took a closer look at those who attended and compared the “likelihood to refer” of those who attended with those who attended and completed the Passport booklet. If the participant attended and completed the Passport booklet, there was not a significant difference on the referral question. This interesting phenomenon was unexpected. There appeared to be potential bias in the sample for those who participated in the event and completed the Passport booklet, possibly due to the overlap between those who attended and those who attended and completed the Passport. In this regard, we excluded the Passport participants from the computations when comparing groups.

Q3: Does stigma toward mental health exist on the university campus?

Stigma appears to exist in the sample. Independent t-test indicated a significant effect for personal experience with psychological help t(1) = 12.92, p < .001, with non-attendees receiving higher scores than attendees (N=318). In addition, those who attended the event scored higher at the 90% confidence level on the ATWPPH-SF than those who did not attend. This could imply a lower level of stigma for those who attended the event although not statistically significant. The implications of this and other responses will be discussed later. Also open-ended responses indicated fears or feelings of stigma.

Discussion and Implications

Testing the first hypothesis did not produce any statistically significant difference on the ATWPPH-SF between the attending and non-attending groups. There is some difference noted, however, at the 90% confidence level providing anecdotal support for future wellness projects. Pre-post designs would also provide additional information for future studies.

For question two there was a significant difference in attendance and participants’ likelihood of referring (if they attended, they scored significantly higher on the "likely to refer" question). This is an important finding as attendance at the mental health fair increased the participant’s likelihood of referring. One might assess that the mental health fair lowered stigmas attached to referring a friend or family member for professional help. However, it is unknown if there is another variable at work; we found a difference between those who attended and did not attend the event, but did not test whether their stigma and likelihood to refer changed from pre- to post-event.

We can only speculate as to why smaller group of participants who completed the Passport booklet scored differently than those who attended and did not complete the Passport. It is possible that these participants were focused on achieving a prize (e. g., entry into the drawing), and did not spend any significant time at one or more booths, or they may have completed the Passport only to receive a grade. Use of the Passport in future events should be evaluated to determine purpose and worth.

Regarding question three, stigma appears to exist in the sample. Non-attendees scored higher on personal experience with psychological help (meaning they had either personally experienced psychological help or had a close friend or family member who had) than those who did not attend the event. We can only speculate as to why these individuals did not attend the event although some responses to their open-ended responses may provide additional insight. Having a history of personal experience with psychological help may have prevented them from participating, for fear of being “exposed.” For example, one participant wrote, “Sometimes I wonder at what point does it make it "okay" to seek professional mental health. The negative association that I have to psychiatric [sic] help from either family or media or whatever makes me more comfortable keeping my problems to myself. Sometimes that means not even opening up to a friend.” Stigmas and marginalization may be in effect in this participant. Further research is indicated on stigmas with regard to the results in this sample.

Although stigmas may be in effect in the sample, there were also participants who found psychological services helpful. Open-ended responses included a need for counseling and awareness of counseling services. For example, another participant wrote, “Most students on campus think that there are not enough campus counselors to meet the need of the student body.” Yet another participant stated, “I think it's a good way to encourage students who may need help to actually get that help.” Other participants reported: “glad to know that there is something available on campus,” and “I hope we have another event like that, it was really amazing!” One participant in the study who could not attend due to class conflicts reported, “Had I been able to attend, I would have appreciated the information available. As it was, I liked what I saw while passing through the area. Good job. :) I have been able to take advantage of the counseling services… and believe they have made me a more confident, healthier person.” The positive remarks we received from these participants lent further credibility to the success of the event.

While it was not a part of the original focus, additional post hoc analysis led to further outgrowth from this experience as well as more surprises. For example, using a Chi Square, males (X=25.25) scored significantly higher (p<.001) on Fischer and Farina’s (1995) help- seeking scale than females (X=16.46). This finding is contrary to literature indicating females are more likely to seek help (Brooks, 2009). It is possible this phenomena is limited to our population and may not be generalizable to other samples; however, the finding exhibits a need for further research and discussion. Future researchers might address social desirability as this could also inflate the scores on help-seeking scales, although one would expect those scores to be equally inflated in both males and females.

It is possible this result is not limited to our population, but is the beginning of a new trend toward male friendly therapy. Perhaps men are more open to therapy now than they have been in the past. More studies are needed in this area as we evaluate our approaches to both genders. Brooks (2009) indicated that therapeutic models need to change for males; male therapists are at a shortage. The finding from this study indicates that males are willing to seek therapy in their time of need.

Limitations

Use of a post facto design is limiting, as the researcher is unable to manipulate the independent variable, i.e., attendance at the event. Therefore, we could not establish true cause- effect (Sprinthall, 2007). We were unable to use a randomly assigned experimental or pre- post- design or random sampling due to the nature of the campus-wide event as well as limitations placed by the gatekeepers in the university. Future researchers interested in evaluating the effectiveness of an event on help-seeking attitudes may consider ways to employ a pre- post random design.

Lessons Learned

As we prepared for the Passport to Wholeness fair, conducted the event, then completed the study, we learned some valuable lessons that may be transferrable to other campuses who want to conduct a wellness event. This section will discuss the keys to having a successful event that we learned from our experience.

The first lesson learned was the value of collaboration. We won’t repeat all the personnel involved in this event, however we acknowledge their support. The campus-wide event connected various departments with one another such as faculty with student services, administration with student life, counseling with community services, academic advising with faculty, etc. These connections served to solidify the awareness on all sides of the campus of their shared purpose for student success. In addition, this venue provided another outlet for counselors and counseling interns to interact with the campus community in a positive manner.

Campus events hosted by counselors and counselor educators further increased awareness in stakeholders of the importance and viability of the counseling department as well as counselor education programs. Historical studies have looked at the connection between academic standings and counseling. For example, Campbell (1965) discovered a positive correlation between academic success and counseling; Frank and Kirk (1975) noted a positive correlation between and counseling and higher graduation rates. Higher retention rates are noted for those students who received counseling than for those who requested counseling and did not receive it (Wilson, Mason & Ewing, 1997). In addition, Turner and Berry’s (2000) study found students who received counseling held higher retention rates compared to the general student body. Armed with information from the literature, counselors can help decision makers examine the benefits of maintaining a solid counseling center.

A potential side benefit that we learned is that well publicized events bring people on campus, increasing visibility in the community and potential for new students and tuition dollars (more rationale for stakeholders). For example, one booth host indicated that she was alum of the university, but had not been back on campus in 20 years. After hosting a booth at this event and noticing positive changes on campus she said she was going to encourage her son, a senior in high school, to apply.

Another lesson involves timing. Campus counseling centers are often overwhelmed with their client base (Gallagher, 2009), so the timing of a campus-wide event is critical. If the event is conducted too close to the beginning of the academic year, students have yet to experience a stressful schedule and the event may not feel applicable. Too far into the year, however, and the campus counselor centers will already feel overloaded with insufficient time to follow-up on referrals that result from the fair. Also, to solicit support from faculty and staff, we looked for a time with the least resistance. Therefore, we chose a time just before mid-terms in the fall semester when stress was high and confirmed it in the campus calendar for early promotion.

Another lesson learned involves promoting the purpose of the event to faculty, staff, and potential participants. The purpose of the event should be well communicated. We were cautious about overemphasizing the purpose during the promotion phase as we didn’t want to unduly influence the results of our study. However, this turned up on our post-evaluation tool as a concern. Communicating the purpose of increasing awareness of mental health issues with each piece of promotional literature is yet another venue for increasing awareness. The following are more logistical lessons, or keys to a successful event.

An important lesson is that events can be successful even on a limited budget. However, it does take money to make copies, purchase supplies, etc. The more administrators and department heads who “buy in” to the project, the more resources that will become available. Also, with our limited budget, we sought donations from community sources who donated supplies as well as hands-on support. This took time to do the networking, but a side benefit was the long-term relationships that were built in the process.

Organization is critical. One person needs to oversee the project and maintain a binder of all aspects. Coordinate parking, tents, activity calendar, marketing, facilities, administration, communication with booth hosts, and set-up/tear-down crew, etc. Most campuses have a student life coordinator who is in charge of campus activities. While that individual may not have an interest or desire to oversee this type of project, he or she can be a valuable source of information for understanding the logistics for campus-specific event planning.

Extend marketing to all students (including commuters) and use multiple methods for promotion. Campus newsletters, email blasts, posters in the dorms, announcements at dorm meetings, and mailbox inserts are just a few of the methods we used to market our event.

Encourage engaging interaction between hosts and students. For example, one respondent suggested, “A lot of the booth vendors did not really know what to say to students so it was kind of awkward to go up and talk to them. They may need sample questions or topics to introduce to students to make the interactions more valuable.” Scheduling a meeting with all hosts before the event decreases their anxiety and makes things run smoother.

In conclusion, the Passport to Wholeness mental health and wellness campus-wide event was conducted on a university campus with a relatively low budget. It brought several on- campus personnel and community resources together through the use of a fair-type environment in an effort to increase awareness of mental health and wellness issues. Stigmas were addressed. A post-event study determined that of the 375 respondents, those who attended the event were more likely to refer a friend or family member for professional counseling than those who did not attend the event. There is a need for further research on the effectiveness of mental health fairs on help-seeking behaviors and stigmas. Males scored higher on the help-seeking scale than females, and possible explanations were proffered. We shared some lessons learned and identified keys to self-producing a successful health and wellness event on other college and university campuses.